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The Most Difficult Emergency Procedure, by Dr Vipul Kella

Wednesday, 23 Oct 2013 17:59

(Editor’s Note: Dr. Kella’s story reflects my own personal journey as an Emergency Physician. All conscientious healthcare providers eventually come to a patient who transforms the way they practice. The lesson in Dr. Kella’s story is especially important for those of us who practice in the Emergency Department, where we set the expectations for our patients and families, and we set the course of care with the therapies that we initiate (or not). It is within our power to change the destinies of those whom we serve, to relieve and prevent their suffering, instead of allowing and creating more.- Monica Williams-Murphy, MD)

When I graduated residency and started my first job, I walked around the ED confidently, chest slightly pumped up at all times. I knew I was well-trained. If there was a sick patient, I was going to resuscitate them. If there was an impossible central line that was needed – I was going to get it. Difficult intubation? No problem. There was no procedure that was too difficult for me.

Many Emergency Medicine graduates probably walk around with a similar sense of confidence today. Most know that when it counts, their expertise will be life-saving. It’s at the core of why they chose to enter emergency medicine to begin with.

As I have progressed in my career, though, my perspective has changed a bit. I still love performing the life-saving procedure and resuscitating the critically ill patient. However in recent years I’ve also realized it is often the procedures that we don’t do and the conversations that we must have that are the most difficult. And no conversations are more difficult than the ones we are sometimes compelled to have regarding end-of-life care.

Last week I was working a night shift in the ER, and an 89 year-old chronically ill woman presented in severe distress. Her skin was cool and cyanotic and she was complaining of shortness of breath. Her blood pressure was extremely low and she had an elevated pulse. It soon became apparent that she was having a massive heart attack that was causing her heart to fail, and her body to go into a shock state. Without urgent intervention she would die. Her son soon arrived to the bedside and was hysterical. “Doc, do whatever you can to save my mom,” he said.

In the past this statement would have been my green light to do any and every procedure that promised a chance of saving this woman. This time though I paused. This was an 89-year old woman that was already bed bound and didn’t have much quality of life. What were we going to accomplish with these heroic measures? I realized that this woman’s life was not likely to be significantly improved even if the treatments worked, and in fact the most likely outcome, in my medical judgement, was that we would only succeed in prolonging her pain and suffering.

I spoke to her son: “Sir, I’m going to be very honest with you. Your mother doesn’t have very much time. We can try a few heroic measures which may prolong her life. In all likelihood though she will never walk out of this hospital alive and if she does her long term quality of life will be very poor.”

He looked at me astonished at my bluntness but still wanted to continue. “Do what you have to do to save her doc.” I tried again. “Sir, if this was my own mother I wouldn’t put her through this. It would be cruel.” He stopped this time and responded. “Doc, I trust you to do what’s right.” I said, “I think we should keep her as comfortable as possible right now, but realize that she doesn’t have much time.”

The son was overcome with emotion but quickly began to come to terms with the fact that his mother would soon be dead. He stayed at the bedside for the next two hours until she finally passed away. He thanked me for being so frank with him at the end.

I left that shift that day with a good feeling. As unfortunate as it was for the son to lose his mother, I felt that I had done the right thing for this patient. The conversation I had with the son, though difficult, allowed him to come to terms with her passing. I knew that day I had successfully performed the most difficult of all emergency procedures.

"It's OK to Die" is a ground-breaking book filled with graphic stories straight out of the Emergency Room illustrating how most Americans are completely unprepared for death and dying. In response, the authors have created a unique and comprehensive guide urging EVERYONE to prepare in advance, to assure their own peace and to prevent the suffering of their loved ones. Learn More..

Beautiful piece! How like your own, Dr. Murphy! This doctor understands the lessons that you teach. There is a cure beyond saving a life. True healing is sometimes holding a hand and guiding an elegant, gracious letting go…a good-enough death. Relieve suffering. Dr. Kella found the way. Now that way belongs to him, and it is his, also, to teach others.

Thank you, Dr. Kella. I say this from the heart, not only as a hospice social worker, not only as the survivor of two hospice patients, but also as an end of life survivor, myself. The manner in which you told this man was exactly right, and your insistence for him to listen to you was admirable. Doctors like you, who do not have to win the war against Death every time, are the ones that I admire the most. My utmost respect to you, sir!

The bigger question is Why hadn’t this patient’s primary care providers had this conversation with her and her son long before this ER visit ?? It’s wonderful that you were able to convince the son of what was in his mother’s best inetrest but if she had any good advance care planning , she might not have even ended up in the ER. This case is an excellent example of why programs like POLST need to be part of all physician’s training and that Advance Care palnning should be a crucial part of health care maintanence.

I agree that people should be discussing EOL issues long before they roll into the ED (as we all know, the Emergency Department should be the last place that someone has their first end of life planning conversation!)
Yes, the POLST makes all of this easier and so does physician/resident/medical student education. I doubt Dr Kella was trained to have this type of conversation ( I know that I wasnt)…so he had to pull his words from a place deep inside, it takes great courage to speak these words in an unpracticed way for the first time.

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